Gearing up for DSM-V

The New York Times has an article on the ongoing fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).  There is good reason to pay attention: the classifications that DSM-V puts forward will end up affecting us all, and as the article points out: 

“This is not cardiology or nephrology, where the basic diseases are well known,” said Edward Shorter, a leading historian of psychiatry whose latest book, “Before Prozac,” is critical of the manual. “In psychiatry no one knows the causes of anything, so classification can be driven by all sorts of factors” — political, social and financial.

Financial indeed.

As exhaustively documented in Christopher Lane's book Shyness, there is a great deal of money at stake whenever DSM is revised.  The book is not really well-named; a more appropriate title would have been "The Definitive History of the DSM".  OK, that would have been boring, but that is really what the book represents.  A sensational title (that the publishers might consider for the next version) might be, "How DSM produced a Windfall for the Pharmaceutical Industry", as the book details some of the pressure that was brought to bear on the framers of earlier versions of DSM.  So what can we expect for DSM-V?

You can find out for yourself by visiting the DSM-V section of the APA's website which gives a sense of what is going behind closed doors, but don't expect to see the kind of information that was revealed in Chrisopher Lane's book: contributors to DSM-V have been asked to sign a non-disclosure agreement.  Again from the NY Times article:

The American Psychiatric Association says the contributors’ nondisclosure agreement is meant to allow the revisions to begin without distraction and to prevent authors from making deals to write casebooks or engage in other projects based on the deliberations without working through the association.

Some critics, however, say the secrecy is inappropriate.

“When I first heard about this agreement, I just went bonkers,” said Dr. Robert Spitzer, a psychiatry professor at Columbia and the architect of the third edition of the manual. “Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.”

As for the ability of the pharmaceutical industry to influence matters, "Scientists who accepted the invitation to work on the new manual — a prestigious assignment — agreed to limit their income from drug makers and other sources to $10,000 a year for the duration of the job."  As is pointed out in the article, this ceiling is lower than that which exists at many academic institutions, and as such is reassuring.  However, I could find nothing on the APA website which indicated that there were any ramifications to individuals reneging on their committment.  It would be wrong to suggest by innuendo that the hard working scientists who are developing DSM-V are not trustworthy - in fact, I am confident that they are.  That being said, the past six months have seen allegations of undisclosed financial income from the pharmaceutical industry against such titans of the field as Joseph Biederman, Charles Nemeroff, and Frederick Goodwin, resulting in a crisis of confidence by the general public in the field of Psychiatry as a whole.  And, of course, it is in the best interests of the pharmaceutical industry to influence the process, so we can assume that they will pursue their business interests to extent that the law allows (OK, perhaps, just this one time, they might push the envelope a little bit).

Given this state of affairs, the architects of DSM-V would be well advised to be scrupulous in their ability to disavow conflicts of interest in the process of developing this new diagnostic manual.  This time around, the world is watching.

Comments

[Patrick S. O'Donnell]

In addition to Lane's book, I would recommend the following as essential to a fair assessment of the virtues and weaknesses of the DSM:

*Bolton, Derek and Jonathan Hill. Mind, Meaning, and Mental Disorder: The Nature of Causal Explanations in Psychology and Psychiatry. New York: Oxford University Press, 2nd ed., 2003.
*Conrad, Peter. The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders. Baltimore, MD: Johns Hopkins University Press, 2007.
*Healy, David. Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression. New York: New York University Press, 2004.
*Horwitz, Allan V. Creating Mental Illness. Chicago, IL: University of Chicago Press, 2002.
*Horwitz, Allan V. and Jerome C. Wakefield. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. New York: Oxford University Press, 2007.
*Hutto, Daniel D. Narrative and Understanding Persons. Cambridge, UK: Cambridge University Press, 2007.
*Hutto, Daniel D. Folk Psychological Narratives: The Sociocultural Basis of Understanding. Cambridge, MA: MIT Press, 2008.
*Murphy, Dominic. Psychiatry in the Scientific Image. Cambridge, MA: MIT Press, 2006.
*Radden, Jennifer, ed. The Philosophy of Psychiatry: A Companion. New York: Oxford University Press, 2004.
*Sadler, John Z. Values and Psychiatric Diagnosis. New York: Oxford University Press, 2005.